Student Emergency / Medical Information Card

San Francisco Unified School District Date

STUDENT(This EM EcardRGE neeNdsCY to be/ M coEmplDIetCedAL every INFORMATION school year) CARD NAME HO# (Last) (First) (Middle Initial) School Grade Age Home Room/Room Birthdate Sex:

Month Day Year M ‰ F ‰ Home Address Apt. No. City Zip Code Home Phone Language Spoken at Home (If different from home address above) Parent / Guardian / Parent / Guardian / Caregiver Name Caregiver Name Employer Employer Home Phone Work Phone Home Phone Work Phone Cell Phone Pager No. Cell Phone Pager No. CHILD LIVES WITH: ‰ Mother ‰ Father ‰ Caregiver/Guardian ‰ Other (specify) EMERGENCY CONTACTS In case child listed above becomes ill or is injured at school and I cannot be contacted, the school authorities have my permission to contact and release my child to the custody of one of the following: Name Relationship Home Phone Cell Phone 1. 2. 3. Health Care Provider Phone To assure prompt attention to your child, PLEASE NO T I FY SCHOOL OF ANY CHANGE OF INFO R MATION ON THIS CAR D . English - STOCK #13-0700 ***IMPORTANT: Please Complete Other Side of Card*** Rev. 3/25/04, SFUSD-SSS (Rev. pdp)

SFUSD Student, Family, and Community Support Department 2014-2015 School Health Manual My child has health insurance: Yes No

If YES, list: Student Address Label Member # NO MEDICAL CONDITION OR  My child receives regular care for the following medical condition(s): Allergies/Allergic to: Date of last reaction: Requires Epinephrine (Circle one): YES NO

Asthma Diabetes - Insulin required? (Circle one): YES NO Seizures -Does your child have any other major health issue(s)? Please list:

-Is your child taking medication(s)? Please list medication(s) and times taken:

Medications / times taken Medications / times taken Medications / times taken - Other chil d ren attend i ng SFUSD sch o ols: Name School Grade

If my child needs to be taken to an emergency facility, he/she will be taken to the nearest one. I give my consent for school authorities to take appropriate action for the safety and welfare of my child.

Rev. 3/25/04, SFUSD-SSS (Rev. pdp) Parent's/Guardian's Signature

***IMPORTANT: Please Complete Other Side of Card***

SFUSD Student, Family, and Community Support Department 2014-2015 School Health Manual